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BCMCH-ED-FORM 001 DOOR TO NEEDLE TIME FOR MI PATIENT
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Date *
MM
/
DD
/
YYYY
TIME OF ARRIVAL *
Time
:
Emp ID *
Area *
SIGNS AND SYMPTOMS *
Yes
No
NA
Central Chest Pain
Excessive sweating
Hypertension
Palpitation
DOE
Radiating Pain on Left arm
Pain on the Shoulder and Back
Heart Burn
Nausea
Vomiting
Abdominal pain
Chest discomfort
Chest heaviness
Patient brought intubated from outside hospital
Seizure Disorder
CO-MORBIDITIES *
Yes
No
NA
ACS
CAD
UNSTABLE ANGINA
STABLE ANGINA
ATRIAL FIBRILLATION
HTN
DM
DLP
AKI
CKD
CVA
PREVIOUS PTCA
PREVIOUS CABG
COPD
Hypo thyroidism
Diabetic Nephropathy
HISTORY COLLECTED *
Yes
No
Detailed examination done by doctors
Pain Score *
INVESTIGATIONS *
Yes
No
NA
Pt INR
Viral Markers
ED Routine
ECG
APTT
ABG
VBG
CRP
Trop i
ECG *
Time
:
ECG  VARIATION *
Yes
No
NA
STEMI
T- Wave invertion
Anterior MI
Antero Lateral MI
Antero Septal MI
Lateral MI
Posterior MI
Inferior MI
Infero Posterior MI
Infero Lateral MI
Inferior Posterior wall + RV MI
Reciprocal changes
NSTEMI
DIAGNOSIS *
Yes
No
NA
STEMI
NSTEMI
UNSTABLE ANGINA
IV CANNULATION *
Time
:
MEDICATION  ADMINISTERED *
Yes
No
NA
On regular medication
Given Outside Hospital
Aspirin 325 mg
Atorva 80 mg
Clopidogrel 300 mg
Clopidogrel 600 mg
Heparin 5000 IU
Inj Emeset 4 mg
Inj. Pantop 40 mg
IV N/S 0.9 500ml
Inj. Morphine 2 mg
Inj. Morphine 5 mg
Inj. Paracetamol 1 gm
Tab. Clopidogrel 300 mg
Thrombolytic therapy Administered *
Name of the Thrombolytic therapy *
Required
ADVERSE REACTION *
Yes
No
NA
Bleeding Gums
Rash
Fever
Chills
Hematuria
HTN
Hypotension
Hematoma
Altered Mental Status
Brady arrhythmia
CHB
AF
VT
VF
Cardiology Consultation Seen *
CCU Shifting *
Time
:
Primary PTCA Done *
Initiation  Time for PCI *
Procedure Done *
Door to Needle Time *
Door to PCI Time *
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